1. Why Is My Child Hoarse?
Irritation of the voice box may cause swelling which can lead to hoarseness. Cigarette smoke or noxious fumes from paint may be prime factors. Chronic nose and sinus disease may contribute to irritation because of postnasal drip. Chronic cough and throat clearing will then further damage already irritated vocal cords.

Allergies may also increase mucous drainage, which worsens swelling of the vocal cords. Air conditioning in the summer and dry heat in the winter can contribute to dryness of vocal cords and lead to irritation. Other factors contributing to irritation are mouthbreathing from chronic nasal congestion, over usage of decongestants, and in older children, smoking and alcohol ingestion.

Other less common causes of hoarseness include:

1. Warts possibly obtained from the birth canal during the child's birth

2. Scarring due to having a breathing tube placed into the voice box for sickness or for routine surgery,

3. Injury to the vocal cord nerves,

4. Generalized nerve or muscle diseases,

5. Injury to the neck and voice box,

6. Tumors and cysts,

7. Abnormal development of the voice box,

8. Stomach acid, which spills up onto the voice box,

9. Foreign body swallowed or inhaled,

10. Infection.

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2. When Should A Child Be Evaluated For Hoarseness?
Hoarseness is a term used to describe a problem of the voice box, which causes an unpleasant rough sounding voice. A sudden onset of hoarseness is usually more alarming to parents and this leads to an urgent doctor evaluation. More commonly, parents themselves often do not notice the hoarseness until teachers, friends or relatives point it out to them. Therefore the time of initial occurrence of hoarseness is usually hard to determine.

Your child's history is extremely important in making the correct diagnosis. The most common cause of hoarseness in children is due to excessive voice use, which leads to the formation of vocal nodules. An accurate assessment of how much stress your child puts on his voice box can be determined by asking if your child screams, imitates loud sounds, or cries, sings, or speaks loudly. These questions may give a general idea of the potential for voice abuse.

Hoarseness should be evaluated when the hoarseness is persistent or interferes with the ability of others to understand the child. Certainly if the symptoms are worsening significantly, treatment should be sought immediately.

Hoarseness in children may vary in severity and in cause. It is important to completely evaluate the child and not assume that the problem is due to voice abuse. Although voice abuse is the most common cause of hoarseness in children, serious underlying problems may also lead to hoarseness.
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3. How Is The Cause Of Hoarseness Found?
A complete evaluation of the entire head and neck areas is very important. Examining the ear may find ear fluid which causes a hearing loss and leads the child to speak louder and irritate the voice box. Examination of the nose may show evidence of allergies, sinus infections and other causes of nasal blockage, which may lead to postnasal drip and mouth breathing, both of which contribute to voice box irritation. Examination of the mouth may reveal enlarged tonsils, which muffle the voice and is mistakenly thought of as hoarseness. Neck masses and scars may give clues about other possible diseases or potential for nerve injury.

Fiberoptic flexible endoscopy is a technique using a flexible telescope to look at your child's voice box in the doctor's office using local anesthesia. It is useful to assess the voice and look for diseases in children over the age of 4 years. In younger children, this procedure is mostly a tool to diagnose diseases because younger children tend to not cooperate with speech assessment while a telescope is inserted into their noses.

Treatment will obviously depend upon the diagnosis. The most common cause of hoarseness in children is vocal nodules (small calluses on the surface of the vocal cords).

Rigid Endoscopy showing bilateral vocal cord nodules
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4. Does My Child Need Speech/voice Therapy?
In every case, early involvement with the speech therapist is important. Even the child whose major problem is vocal cord irritation may benefit from speech therapy. Children with voice abuse need cooperation from speech therapists, teachers and family members. Attention must be placed on finding the areas of voice abuse and changing the child's habits with behavior modification.

With maximal treatment of voice abuse, the vocal nodules usually resolve.

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5. Do Vocal Nodules Have To Be Removed?
If in spite of the treatment and behavioral changes, the vocal cord nodules and hoarseness remain, the nodules can be removed with surgery. If long-term speech therapy has been unsuccessful, the removal of the nodules may improve the voice. However, if the voice abuse patterns are not changed, there is a good chance that the nodules will come back. Continued speech therapy after surgical removal of vocal nodules is always helpful.

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